Nursing Elites

1. A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse’s priority action?

• A. Obtain a urine sample for toxicology screening
• B. Discuss treatment options with the parents
• C. Establish a therapeutic relationship with the adolescent
• D. Administer a medication to reverse the effects of the substance

Correct answer: A

Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. By knowing the specific substances, healthcare providers can tailor treatment plans effectively. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan. Administering a medication to reverse substance effects is not the initial priority; identification of the substances through toxicology screening should precede any treatment intervention.

2. The nurse is conducting an admission assessment of an 11-month-old infant with CHF who is scheduled for repair of restenosis of coarction of the aorta that was repaired 4 days after birth. Findings include blood pressure higher in the arms than the lower extremities, pounding brachial pulses, and slightly palpable femoral pulses. What pathophysiologic mechanisms support these findings?

• A. The aortic semilunar valve obstructs blood flow into the systemic circulation
• B. The lumen of the aorta reduces the volume of the blood flow to the lower extremities
• C. The pulmonic valve prevents adequate blood volume into the pulmonary circulation
• D. An opening in the atrial septum causes a murmur due to a turbulent left-to-right shunt

Correct answer: B

Rationale: The correct answer is B. Coarctation of the aorta causes narrowing of the aorta, reducing blood flow to the lower extremities. This narrowing results in higher blood pressure in the arms compared to the lower extremities, along with stronger brachial pulses and slightly palpable femoral pulses. Choices A, C, and D are incorrect because they do not align with the pathophysiological mechanism of coarctation of the aorta, which specifically leads to reduced blood flow to the lower extremities.

3. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?

• A. Stimulate the infant to cry to produce cyanosis
• B. Auscultate the heart and lungs while holding the infant
• C. Evaluate the infant for failure to thrive
• D. Obtain a 12-lead electrocardiogram

Correct answer: B

Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.

4. What suggestion should the nurse provide to prevent diaper rash in a 4-month-old infant as requested by the mother?

• A. Generously powder the baby's diaper area with talcum powder at each diaper change to promote dryness.
• B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown.
• C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change.
• D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely.

Correct answer: C

Rationale: Using a barrier cream like zinc oxide forms a protective layer on the skin, creating a barrier against irritants and moisture, thus helping to prevent diaper rash. Unlike other options, barrier creams do not need to be completely removed at each diaper change, allowing the skin to remain protected between changes.

5. A 13-year-old client with type 1 diabetes presents to the clinic with a blood glucose level of 400 mg/dL. The client reports feeling thirsty and having frequent urination. What is the nurse’s priority action?

• A. Administer insulin as prescribed
• B. Encourage the client to drink water
• C. Check the client’s urine for ketones
• D. Reinforce the importance of diet and exercise

Correct answer: A

Rationale: In a client with type 1 diabetes presenting with hyperglycemia (blood glucose level of 400 mg/dL) and symptoms of thirst and frequent urination, the priority action for the nurse is to administer insulin as prescribed. Insulin helps lower the blood glucose level and prevents complications like diabetic ketoacidosis. While encouraging hydration is essential, administering insulin is crucial to address the high blood glucose levels. Checking urine for ketones is important in diabetic management but is secondary to administering insulin in this scenario. Reinforcing diet and exercise importance is vital for diabetes management but not the priority in acute hyperglycemia.

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